为了建立医疗机构质量监管长效机制，市卫生局近期出台《医疗质量管理考核评价细则(试行)》，并于10月22日起正式实施。这也标志着今后我市公立医院质量监管有了明确依据。该《细则》涵盖了九大方面内容和214项具体考核指标，对考核不达标或者存在问题的项目将按规定实行扣分，考核分值将与医院评优绩效等挂钩。

In order to establish the medical institution quality supervision mechanism,City health bureau recently issued[Medical quality management evaluation rules(trial)],And in the October 22, the formal implementation.It also marked the future city public hospital quality supervision have clear basis.this[rules]Covers the nine aspects and 214 projects under the specific evaluation index,Not in the evaluation standard or existing problems of the project will be a penalty in accordance with the provisions,Assessment score will be linked to performance assessment and hospital.

　九大措施狠抓医疗质量 Nine measures vigorously promotes the medical quality

　　该《细则》是市卫生局结合公立医院改革、“医疗质量万里行”以及抗菌药物专项整治等监管措施，对我市二级以上医院出台的具体考核评价依据。涵盖了九大方面的内容：其一，落实各项医疗制度，实施临床路径管理，保证医疗质量和医疗服务的安全性和有效性；其二，加强医疗机构管理、强化服务意识、优化服务流程、提高医疗服务水平，改善人民群众看病就医感受；其三，落实患者安全目标，实施院务公开，规范医疗机构相关科室建设；其四，加强医疗技术临床应用管理；其五，加强医疗机构药事管理，推进临床

this[rules]Is combined with the municipal bureau of health, public hospital reform/"Medical quality tour"And antimicrobial drug special regulation and supervision measures,For zhuhai's second class above hospital on the introduction of the specific evaluation basis.Covers the nine aspects of content:one,Implement system of medical treatment,The clinical pathway management,Ensure the quality of medical treatment and medical service safety and effectiveness;The second,To strengthen the administration of medical institutions/Strengthen the service consciousness/Optimization service process/To improve the medical service level,Improve people's hospital feeling;thirdly,Implement patients safety target,Implementation of public management,Standard the medical institutions related department construction;its,To strengthen the medical technology clinical application management;five,Strengthen the drug management of medical institutions,Propulsion clinical

　　合理用药；其六，加强护理工作，落实基础护理，改善护理服务，提高护理质量；其七，认真贯彻落实《医院感染管理办法》，预防和控制医院重点部门、重点环节的医院感染；其八，加强实验室生物安全和质量控制；其九，加强安全生产责任制落实，保障医疗安全。

Rational drug use;The six,To strengthen the nursing work,Implement basic nursing,Improve nursing service,Improve nursing quality;The seven,Conscientiously implement the[Measures for the management of hospital infection],To prevent and control hospital key sectors/Key link of hospital infection;The eight,To strengthen the laboratory biological safety and quality control;The nine,To strengthen the safe production responsibility system implement,To protect the safety of medical treatment.

　服务流程超时将被扣分 Service flow over time will be given

　　该《细则》共包括214条具体考核细则，其中涉及医护人员业务的考核项目最多。患者入院48小时内无主治医师查房记录；主治医师每周查房少于2次、主任医师每周查房少于1次以及正、副院长是否每周轮流值班都是抽查的范围。考核细则还对医院服务流程时间做了限制。对挂号、划价、收费、取药等服务窗口等候时间超过10分钟；超声检查自检查开始到出具结果时间超过30分钟；大型设备检查项目自开具检查报告申请单到出具检查结果时间超过48小时；血、尿、便常规检验及心电图、影像常规检查项目自检查开始到出具结果时间超过30分钟；生化、凝血、免疫等检验项目自检查开始到出具结果时间超过6小时；细菌学等检验项目自检查开始到出具结果时间超过4天；术中冰冻病理切片自送检到出具结果时间超过30分钟要进行扣分。

this[rules]Article 214 includes a detailed examination of the detailed rules,Involving medical personnel assessment project of the business the most.Patients to the hospital within 48 hours without attending doctor ward inspection records;The attending physician patient rounds a week less than 2 times/Chief physician patient rounds a week less than 1 times and is/Whether the vice President of the weekly turn on each other are the scope of the selective examination.Assessment rules of hospital service flow time to do the limit.To address/To calculate/charge/Medicine and other services window time waiting for more than 10 minutes;Ultrasound examination from start to check issued by the results of time more than 30 minutes;Large scale equipment inspection project since the draw inspection report issued by an application form to check the results put in more than 48 hours;blood/urine/Then regular inspection and electrocardiogram/Image routine inspection projects from start to check issued by the results of time more than 30 minutes;biochemical/clotting/Immune etc inspection items from start to check issued by the results of time more than 6 hours;Such as bacteriology inspection items from start to check issued by the results of time more than four days;Intraoperative frozen pathological section from the inspection certificate issued by the results of time more than 30 minutes to carry on the point deduction.

　护理不到位被投诉扣5分 Nursing does not reach the designated position is complaint buckles 5 points

　　《细则》要求，护理部要按照临床护理工作量对全院临床科室护士进行合理配置和调配。责任护士要掌握所负责患者的病情、观察重点、治疗要点、饮食和营养状况、身体的自理能力等情况，并能够与主管医师相配合。对照病历，如果被抽查病房责任护士对所负责患者情况不掌握或掌握不清将被扣2分。医院病房护士与实际病床总数比低于0.4∶1，ICU实际床位与护士比未达到1∶2.5-3，要扣4分。另外，医院要定期进行病人满意度调查，对患者的投诉进行调查处理。如果在抽查时发现患者有投诉、意见将被扣5分。

[rules]requirements,Nursing department according to the clinical nursing workload partial to clinical nurse reasonable allocation and deployment.Responsibility nurse to master are responsible for a patient's condition/Observation key/Treatment points/Diet and nutritional status/The body's physical ability, etc,And can and competent physician phase fit.Control medical records,If that is selectived examination ward duty nurse to responsible for the conditions of patients don't master or master is not clear will be withholding 2 points.The hospital ward nurses and the actual total beds is lower than 0.4:1,The actual ICU beds and nurse ratio is not up to 1:2.5-3,Four points to buckle.In addition,The hospital to regular patient satisfaction survey,To conduct investigation and deal with complaints.If the spot check found that patients complaints/Opinion will be buckles 5 points.

　　抽查医院未实现护士薪酬分配合理和实现同工同酬的也会被扣分。(记者 杨志彬)

Check the hospital unrealized nurse salary distribution reasonable and realize the equal pay for equal work will be given.(Reporter YangZhiBin)